Onychomycosis (also known as dermatophytic onychomycosis[1] or tinea unguium[1]) is a fungalinfection of the nail.[2] It is the most common disease of the nails and constitutes about half of all nail abnormalities.[3]

This condition may affect toenails or fingernails, but toenail infections are particularly common. It occurs in about 10 percent of the adult population.[4]

The most common symptom of a fungal nail infection is the nail becoming thickened and discoloured: white, black, yellow or green. As the infection progresses the nail can become brittle, with pieces breaking off or coming away from the toe or finger completely. If left untreated, the skin can become inflamed and painful underneath and around the nail. There may also be white or yellow patches on the nailbed or scaly skin next to the nail,[5] and a foul smell.[6] There is usually no pain or other bodily symptoms, unless the disease is severe.[7] People with onychomycosis may experience significant psychosocial problems due to the appearance of the nail, particularly when fingers – which are always visible – rather than toenails are affected.[8]

Dermatophytids are fungus-free skin lesions that sometimes form as a result of a fungus infection in another part of the body. This could take the form of a rash or itch in an area of the body that is not infected with the fungus. Dermatophytids can be thought of as an allergic reaction to the fungus.

The causative pathogens of onychomycosis include dermatophytes, Candida, and nondermatophytic molds.[9] Dermatophytes are the fungi most commonly responsible for onychomycosis in the temperate western countries; while Candida and nondermatophytic molds are more frequently involved in the tropics and subtropics with a hot and humid climate.[10]

Aging is the most common risk factor for onychomycosis due to diminished blood circulation, longer exposure to fungi, and nails which grow more slowly and thicken, increasing susceptibility to infection. Nail fungus tends to affect men more often than women, and is associated with a family history of this infection.

Other risk factors include perspiring heavily, being in a humid or moist environment, psoriasis, wearing socks and shoes that hinder ventilation and do not absorb perspiration, going barefoot in damp public places such as swimming pools, gyms and shower rooms, having athlete's foot (tinea pedis), minor skin or nail injury, damaged nail, or other infection, and having diabetes, circulation problems, which may also lead to lower peripheral temperatures on hands and feet, or a weakened immune system.[11]

White superficial onychomycosis (WSO) is caused by fungal invasion of the superficial layers of the nail plate to form "white islands" on the plate. It accounts for only 10 percent of onychomycosis cases. In some cases, WSO is a misdiagnosis of "keratin granulations" which are not a fungus, but a reaction to nail polish that can cause the nails to have a chalky white appearance. A laboratory test should be performed to confirm.[16]

Proximal subungual onychomycosis is fungal penetration of the newly formed nail plate through the proximal nail fold. It is the least common form of tinea unguium in healthy people, but is found more commonly when the patient is immunocompromised.[9]

Candidal onychomycosis is Candida species invasion of the fingernails, usually occurring in persons who frequently immerse their hands in water. This normally requires the prior damage of the nail by infection or trauma.

A person's foot with a fungal nail infection ten weeks into a course of terbinafine oral medication. Note the band of healthy (pink) nail growth below the remaining infected nail[vague]

In approximately half of suspected nail fungus cases there is actually no fungal infection, but only nail deformity.[18] Because of this, a confirmation of fungal infection should precede treatment.[18] Avoiding use of oral antifungal therapy in persons without a confirmed infection is a particular concern because of the side effects of that treatment, and because persons without an infection should not have this therapy.[18]

Treatment of onychomycosis is challenging because the infection is embedded within the nail and is difficult to reach. It may take a year or more, since new nail growth must entirely replace old, infected growth.[19]

Most treatments are topical or oral antifungal medications.[4] Oral medications include terbinafine (76% effective), itraconazole (60% effective) and fluconazole (48% effective).[4] They share characteristics that enhance their effectiveness: prompt penetration of the nail and nail bed,[20] persistence in the nail for months after discontinuation of therapy.[21]

Oral terbinafine is better tolerated than itraconazole.[22] For superficial white onychomycosis, systemic rather than topical antifungal therapy is advised.[23]

Topical agents include ciclopirox nail paint, amorolfine or efinaconazole.[24][25][26] Topical treatments need to be applied daily for prolonged periods (at least 1 year).[25] Topical ciclopirox results in a cure in 6% to 9% and amorolfine might be more effective.[4][25] Ciclopirox when used with terbinafine appears to be better than either agent alone.[4]

Following effective treatment recurrence is common (10-50%).[4] Nail fungus can be painful and cause permanent damage to nails. It may lead to other serious infections if the immune system is suppressed due to medication, diabetes or other conditions. The risk is most serious for people with diabetes and with immune systems weakened by leukemia or AIDS, or medication after organ transplant. Diabetics have vascular and nerve impairment, and are at risk of cellulitis, a potentially serious bacterial infection; any relatively minor injury to feet, including a nail fungal infection, can lead to more serious complications.[27]Osteomyelitis (infection of the bone) is another, rare, possible complication.[5]

A 2003 survey of diseases of the foot in 16 European countries found onychomycosis to be the most frequent fungal foot infection and estimates its prevalence at 27%.[28][29] Prevalence was observed to increase with age. In Canada, the prevalence was estimated to be 6.48%.[30] Onychomycosis affects approximately one-third of diabetics[31] and is 56% more frequent in people suffering from psoriasis.[32]

Research suggests that fungi are sensitive to heat, typically 40–60 °C (104–140 °F). The basis of laser treatment is to try and heat the nail bed to these temperatures in order to disrupt fungal growth.[33] There is ongoing research as of 2013 which looks promising.[4]

^Elewski, BE; Hay, RJ (August 1996). "Update on the management of onychomycosis: highlights of the Third Annual International Summit on Cutaneous Antifungal Therapy.". Clinical infectious diseases: an official publication of the Infectious Diseases Society of America23 (2): 305–13. PMID8842269.